Case Report: RA Patient Suffers Methotrexate-Induced Cutaneous Lesions

In Sum

This case highlights the importance of patient education regarding the administration of methotrexate and its potential side effects if taken incorrectly. A patient’s current medication list should be reviewed in detail to ensure they are not taking medication that could increase the toxicity of MTX by decreasing renal clearance. Finally, rheumatologists should be aware of the appearance of cutaneous lesions due to MTX toxicity, because they may be the first indicator of systemic toxicity. 

Nitasha Kumar, MD, is a rheumatology fellow at Ochsner Medical Center in New Orleans.

Acknowledgments: Dr. Kumar thanks William Davis, MD, and Karen Toribio, MD, attending rheumatologists at Ochsner Medical Center in New Orleans, for their mentorship and assistance with this article.

References

1. Lewis HA, Nemer KM, Chibnall RJ, et al. Methotrexate-induced cutaneous ulceration in 3 non-psoriatic patients: Report of a rare side effect. JAAD Case Rep. 2017 Apr 14;3(3):236–239.
2. Tian H, Cronstein BN. Understanding the mechanisms of action of methotrexate: Implications for the treatment of rheumatoid arthritis. Bull NYU Hosp Jt Dis. 2007;65(3):168–173.
3. Shiver MB, Hall LA, Conner KB, et al. Cutaneous erosions: A herald for impending pancytopenia in methotrexate toxicity. Dermatol Online J. 2014 Jul 15;20(7):5.
4. Bookstaver PB, Norris L, Rudisill C, et al. Multiple toxic effects of low-dose methotrexate in a patient treated for psoriasis. Am J Health Syst Pharm. 2008 Nov 15;65(22):2117–2121.
5. Suzuki K, Doki K, Homma M, et al. Co-administration of proton pump inhibitors delays elimination of plasma methotrexate in high-dose methotrexate therapy. Br J Clin Pharmacol. 2009 Jan;67(1):44–49.
6. Delyon J, Ortonne N, Benayoun E. Low-dose methotrexate-induced skin toxicity: Keratinocyte dystrophy as a histologic marker. J Am Acad Dermatol. 2015 Sep;73(3):484–490.